Ethics - Issues in Theory and Practice

Issues in Theory and Practice Developing a Counseling Style       Ideally, the theoretical approach you use to guide your practice is an expression of you as a person and is the result of intensive study, reflection, and clinical experience. Ultimately, your counseling orientation and style must be appropriate for the type of counseling you do and the unique needs of your client Theories of counseling are based on worldviews, each with its own values, biases, and assumptions of how best to bring about change in the therapeutic process Many of the assumptions of contemporary theories are inappropriate for evaluating clients from cultures that focus on interdependence, downplay individuality, and emphasize being harmony with the universe Practicing counseling without and explicit theoretical rationale is somewhat like trying to sail a boat without a rudder. A theoretical orientation is not a rigid structure that prescribes specific steps of what to do in a counseling situation o Rather, it is a set of general guidelines that counselors can use to make sense of what they are hearing and what needs to change The Division of Responsibility in Therapy    One way to clarify the shared responsibility in a therapeutic relationship is by a contract, which is based on a negotiation between the client and the therapist to define the therapeutic relationship a contract encourages client and therapist to specify the goals of therapy and the methods likely to be employed and obtaining these goals therapists who work within a managed care context needed discuss with clients helping involved with managed care will influence division of responsibility between the HMO, the client, and the therapist Deciding on the Goals of Counseling       Both therapist and client should clearly understand the goals of their work together in the desired outcomes The aims of therapy are specific to a particular culture's definition of psychological health; no single approach is equally effective in working with all client populations In a managed care system, the goals will need to be highly specific, limited to reduction of problematic symptoms, and often aimed at teaching coping skills In crisis intervention, goals are likely to be short term and functional, and you may be much more directive In schools, you may combine educational and therapeutic goals In serving older adults residing in assisted living community, you may stress coping skills and ways of relating to other residents The Use of Techniques in Counseling     Practitioners need to function with intentionality o Must have a clear understanding and a sense of expected outcomes in their interventions Some specific techniques appear to be more effective with particular symptoms and disorders, especially for certain behavioral disorders The therapeutic alliance enhances the quality of the working relationship The techniques counselors employ, although important, or less crucial to therapy outcomes then are the interpersonal factors operating in the client-counselor relationship Assessment and Diagnosis as Professional Issues  Key terms: o Assessment o Diagnosis o DSM-5 o Psychodiagnosis or psychological diagnosis o Differential diagnosis Theoretical Perspectives on Assessment and Diagnosis            Psychoanalytic therapy Adlerian therapy Existential therapy Person-Centered therapy Gestalt therapy Behavior therapy Cognitive-Behavioral therapy Reality therapy Feminist therapy Postmodern approaches Systemic approaches DSM-5    Rather than utilizing the multiaxial system that has been in place for some time, the latest edition of the DSM has moved to a nonaxial documentation of diagnosis In the DSM-5 revision process, the American Psychiatric Association paid considerable attention to: o Developmental Issues o Gaps in the current system o Disability and Impairment o Neuroscience o Cross-cultural issues Lacks and operational framework for assessing distress when diagnosing a mental disorder    An increasing number of phenomena that were previously considered “clinically unremarkable” are now treated pharmacologically The authors of the DSM-IV have critiqued the authors of the DSM-5 for expansions that they believe will cause harm from over-diagnosis and false-positives in practice National institute of Mental Health (NIMH) announced plans to develop its own psychiatric nosology, the Research Domain Criteria (RDoC), which would classify mental disorders based on specific functional analysis of certain cells, genes, neural circuits, and behaviors. The Case for Psychodiagnosis           Used to assess whether clients pose danger to self or others Allows therapists to rule out medical conditions Provides team members with a common frame of reference Can assist in conceptualizing a case Difficult to formulate treatment plan without defining problem Provides framework for research May be critical to determine for therapeutic success May Seldom have a choice about diagnosis May be a minimum standard of care for some licensed professionals No insurance reimbursement without acceptable diagnosis The Case Against Psychodiagnosis          Done by an expert observing a person’s behavior and experience from an external viewpoint Can minimize uniqueness of client Ignores natural capacities for self-healing Emphasis of DSM is on pathology Can lead people to accept self-fulfilling prophecies Assumes that distress in family is result of individual pathology Does not adequately consider contextual, social, and cultural factors Many therapists are not competent to use DSM diagnosis properly DSM has been criticized (reliability and validity questioned, failure to predict treatment outcomes) Ethical and Legal Issues in Diagnosis     Some practitioners who are opposed to a diagnostic framework take the path of least resistance, giving every client the same diagnosis Presenting an “acceptable” but inaccurate diagnosis is both unethical and fraudulent It is an ethical (and sometimes legal) obligation of therapist to be mindful that a medical evaluation is many times indicated Competence in using the DSM appropriately is an ethical issue Cultural Issues in Assessment and Diagnosis        The DSM is based on western American assumptions which limits its usefulness among different cultural groups Cultural sensitivity is essential in making a proper diagnosis What is considered healthy can vary greatly from one culture to the next Failure to give adequate weight to cultural factors can result and misdiagnoses that perpetuate stereotypes based on race, ethnicity, gender, in sexual orientation Accurate assessment and diagnosis involves taking into consideration realities of discrimination, oppression, end racism in society and mental health disciplines Give extra attention to avoid misdiagnosing and pathologizing certain cultural groups We all live in culture contexts that shape our way of being in the world, so it is essential for all of us to assess and address cultural meanings and contextual variables Using Tests in Counseling  It is important for counselors to: o Be familiar with tests being used and take tests themselves o Recognize limits of competence to use and interpret tests o No reasons why a particular test is being used o Make clients aware that tests are merely tools that can provide useful information o Select test appropriate for client given their unique culture, social, and cognitive factors o Give test results, not simply test scores o Be sensitive to ways clients respond to results o Assure clients that test results will not be used against them o Assure confidentiality unless consent is given o Know the limitations of tests being used Evidence-Based Therapy Practice     APA presidential task forces definition, 2006: o “The integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.” The three pillars of EBP: o Best available evidence, clinical expertise, and client characteristics EBP is often associated with cognitive behavioral approaches o These approaches are the most extensively researched psychotherapies Empirically supported treatments: o The movement toward grounding psychotherapy practice on a scientific foundation led to this concept o Proponents believe that each form of therapy needs to be tested in carefully controlled experimental research o The movement has been the source of much controversy since its inception Findings from Psychotherapeutic Research         Therapy is helpful to the majority of clients Most people achieve some change relatively quickly in therapy People change more do to “common factors” than to “specific factors” associated with therapies In general, the various therapeutic approaches achieve similar outcomes The relationship between therapist and client is the best predictor of treatment outcome Most therapists learn more about effective therapy techniques from their experience than from the research Approximately 10% of clients get worse as a result of therapy Experts showed strong agreement that research does not support the following assertions o Placebo control groups and weightless control groups are as effective as psychotherapy o Therapist experience is a strong predictor of outcome o Long-term therapy is more effective than brief therapy for the majority of clients